Alcohol: Impact and Reduction Pat Jackson, RN National TEAP Consultant Sara Mackenzie, MD, MPH San...

Alcohol: Impact and Reduction

Pat Jackson, RNNational TEAP Consultant

Sara Mackenzie, MD, MPHSan Francisco Regional Medical Consultant

Understanding Alcohol Risks on Center

• Describe relationship of alcohol use to employability

• Identify drinking patterns and risks associated with alcohol use among youth

• Review screening and intervention options

• Practice brief clinical intervention

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Issues

• Reporting inaccurate• Alcohol-related issues not

recognized• Alcohol related issues not reported• All of this is why we are here

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Alcohol Statistics

WHY ARE WE HERE?

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What percentage of industrial injuries are linked to alcohol use?

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 47%

Source: Workers Compensation News Network

What percentage of heavy alcohol users hold down a job?

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 74%

Source: National Drug Free Workplace Alliance

What percentage of adults who are employed full time drink alcohol?

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 63%

Source: National Survey on Drug Use and Health 2007, SAMHSA

Job Corps Statistics

• Alcohol separations for six months ending February 28, 2009 numbered 167. This is less than one percent of the total separations.

• During the last program year, 70.5% of the students tested for alcohol use were positive.

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Job Corps Statistics

• There were 288 significant incidents in the last program year that were reported as related to alcohol.

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Alcohol Use among High School Youth

• Most widely used substance by youth (12th grade students in U.S.) – 44.4% report use of alcohol in past 30

days– 21.9% report use of any illicit drug– 18.8 % report use of marijuana

• 28.7% of 12th graders report being drunk

Source: Monitoring the future. National results on adolescent drug useOverview of key findings 2007

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Trends Over Past 30 Years

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Trends Over Past 30 Years

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Subgroup Differences for Alcohol

• Males generally have higher rates of heavy drinking than females

• Students who are not college bound have higher rates of drinking heavily

• South and west generally lower rates of drinking

• Rates of binge drinking roughly equivalent among socioeconomic levels

• Whites>Hispanics>African Americans

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Young Adults in Primary Care

*Grossberg PM, Brown D, Fleming M. Ann Fam Med. 2004:2;474-48018-25 year olds, Wisconsin primary care patients, n=2,460

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Negative Results of Alcohol Use

• Educational difficulties• Psychosocial problems• Physical harm

– Overdose– Injury – Sexual high risk behavior– Alcohol impaired driving

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Role of Alcohol in U.S. Violent Deaths

• 50,000 die annually from violence related injury in U.S.

• Data from 16 states:– 55.9% suicide– 28.2% homicide– 15.1% undetermined intent– 0.7% unintentional firearm

Source: MMWR Surveillance for Violent Deaths. Nat’l Violent DeathReporting System. 16 States, 2006. March 20, 2009 58(SS01);1-44

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Death from Violence-Related Injury

Of the 76% of decedents tested– 32% positive for alcohol– 24.5% positive for opiates– 15.6% positive cocaine– 11.9% positive marijuana – 4.7% positive amphetamines

Source: MMWR Surveillance for Violent Deaths. Nat’l Violent DeathReporting System. 16 States, 2006. March 20, 2009 58(SS01);1-44

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College Health Intervention Projects (CHIPs)

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CHIPs Preliminary Data

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Opportunities to Change?

• Every student’s contact with faculty or staff for academics, advising, housing, student affairs, counseling, or clinical interactions is an opportunity to elicit a prevention “motivational moment”

• Brief, student-focused, related to current concern and designed to stimulate specific effort toward behavior change

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Screening on Admission Form:

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Opportunities to Screen

• On admission• At medication checks• At acute visits• At follow up visits• After “incidents”

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Different Drinking Levels

• At-risk drinking– Men: greater than 4 drinks per

occasion or 14 drinks per week– Women: greater than 3 drinks per

occasion or 7 drinks per week• Alcohol abuse• Alcohol addiction

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CAGE Screen-Test for Alcohol Dependence

• Have you ever felt you should cut down on your drinking?

• Have people annoyed you by criticizing your drinking?

• Have you ever felt bad or guilty about your drinking?

• Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover?

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Specialized

Treatment

Primary

Prevention

Brief

Intervention

None

Mild

Moderate

Severe

Thresholds for

Action

Spectrum of Intervention Response

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Brief Alcohol Interventions

• Cochrane Collaboration• Multiple studies of different interventions

show efficacy of brief interventions in primary care settings

• All utilize screening, feedback on alcohol use and harms, identification of high risk situations, increase motivation and development of plan to reduce

• 5-15 minutes at 1 to 4 visits

Source: Effectiveness of brief alcohol interventions in primary care populations. Kaner ER, Dickinson HO, Beyer FR et al. Cochrane Data base of Systematic Reviews 2007 Issue 2

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Brief Clinical Intervention

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Screening Moments

• At med checks?– Zoloft, paxil, prozac, lexapro, celexa– Adderall, ritalin– Antihypertensives– Non-steroidal medications – Tylenol– Dilantin– Narcotics…

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Brief Screening for Alcohol Use

• Frequency– “How many days per week do you drink

alcohol?”• Quantity

– “How many drinks will you have when you drink?”

• Binge drinking– “How many times per month will you drink

more than (4 or 5) drinks on a single occasion?”

– “Do you ever drink to the point of being drunk?”

Fleming, M.F., & Graham, A.W. (2001); "Screening and Brief Interventions for Alcohol Use Disorders in Managed Care Settings;" Recent Developments in Alcohol, 15, 393-416National Institute on Alcohol Abuse and Alcoholism (1995); The Physicians' Guide to Helping Patients with Alcohol Problems. (DHHS NIH Pub No. 95-3769), Washington, DC: U.S. Government Printing Office..

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Ask likes and dislikes

• What do you like about alcohol?– The buzz, relaxing, fun– Taste– Being with friends, social…

• What do you dislike about alcohol?– Hangovers, passing out– Cost– Calories…

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Social Norms

Do you drink more or less than people your age?

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Drinking Consequences

• People often report the following things have happened while drinking, have any of the following happened to you?– Did something they regret– Drove after drinking– Had an injury– Memory loss/black out– Argued with friends– Had unplanned sex– Fell behind in school or work

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Goals and Plans

• What are you hoping to accomplish in the next 3 months? 6 months? Year?

• Will drinking at your current level make that easier? Harder? No different?

Develop discrepancy

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Express Concern

• I am concerned about your level of drinking because…

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Principles of Motivational Interviewing

• Roll with resistance– Reflect, reframe, redirect

• Express empathy– Reflective listening

• Avoid argumentation– Or direct confrontation

• Develop discrepancy– Between goals and behavior

• Support self-efficacy– Optimism, ability to make changes

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Readiness to Change

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Make a Plan

• It sounds like you might be ready to make some changes. What would you like to do?– Reduce number of drinks per occasion– Reduce number of days drinking– Not drive after drinking– Avoid hard liquor

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Follow Up

• Why don’t we check in next week when you come to pick up your medications…

• Let’s make an appointment in 2 weeks for follow up of your blood pressure…

• ???

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Practice Session

• Screening questions• Ask likes and dislikes• Social norms • Drinking consequences• Goals and plans• Express concern• Assess readiness to change• Make a plan• Follow up

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All educational events must meet the following standards:

• Training content must be current and designed to include recent developments. –NAADAC